Wiki Auditing Residents hospital note with no CC

MargoR

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Good Afternoon everyone,
I have a question.. I have a resident using a SOAP note, no chief complaint.
Here is part of the note:
Problem List:
Acute cholecystitis

Subjective:
I have seen and evaluated this patient this morning. Pt reports the pain has resolved with the pain medication and the nausea has improved as well.
Patient denied fever, chills, diarrhea, constipation, SOB, urinary symptoms.

Objective:
Vital Signs: See below


The supervising MD co-signs and completes attestation to the resident note:
Patient was admitted overnight with acute cholecystitis. Perioperative evaluation has been done, she is low risk for cholecystectomy. Reports adequate pain control at the time of my evaluation, appreciate further recommendations from the general surgery team. I have seen the patient at the bedside and discussed with the resident team. I reviewed the documented findings and agree with the assessment and planning. Please refer to the Resident note for further details.



My question is, Can I use the supervising MD documentation for the chief complaint?
 
Of course you can use the supervising MD documentation - that is part of the record and is documented by a qualified provider who was personally seen and evaluated the patient as part of this encounter.
 
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